甲状旁腺全切除术治疗肾性继发性甲状旁腺功能亢进症近期疗效观察

Short-term effect of parathyroidectomy on renal secondary hyperparathyroidism

目的观察肾性继发性甲状旁腺功能亢进症(secondary hyperparathyroidism,SHPT)患者行甲状旁腺全切除术(total parathyroidectomy,TPTX)或TPTX联合自体移植术(total parathyroidectomy with autotransplantation,TPTX+AT)后血钙、血磷及血清全段甲状旁腺激素(intact parathyroid hormones,iPTH)、碱性磷酸酶(alkaline phosphatase,ALP)水平变化,探讨其治疗效果和安全性。方法肾性SHPT患者62例,行TPTX或TPTX+AT治疗。记录手术成功率及术后并发症发生情况;比较术前及术后1、3、6个月时血钙、血磷及血清iPTH、ALP水平;比较术前及术后6个月时骨痛视觉模拟评分(visual analogue scale,VAS)、皮肤瘙痒及睡眠障碍发生率;随访至2020年4月,记录术后SHPT复发及持续性甲状旁腺功能低下发生情况。结果62例患者中24例行TPTX,38例行TPTX+AT,手术成功率100%,行TPTX+AT者移植物存活率为86.8%,术后均未发生切口感染、喉部感觉神经丧失、失音等并发症,无围术期死亡。血钙、血磷及血清iPTH、ALP水平在术后1个月[(2.26±0.20)mmol/L、(1.09±0.29)mmol/L、73.74(64.50,86.26)ng/L、223.18(44.87,318.86)u/L]、3个月[(2.26±0.21)mmol/L、(1.28±0.25)mmol/L、72.37(64.13,84.40)ng/L、131.98(43.52,199.61)u/L]、6个月[(2.27±0.22)mmol/L、(1.33±0.24)mmol/L、71.11(60.06,83.04)ng/L、104.78(35.36,154.91)u/L]时均低于术前[(2.66±0.15)mmol/L、(2.89±0.70)mmol/L、1277.32(1012.35,1423.85)ng/L、567.68(445.10,741.50)u/L](P<0.05);术后3、6个月时血磷水平均高于术后1个月时(P<0.05),血清ALP水平均低于术后1个月时(P<0.05);术后6个月时血磷水平高于术后3个月时(P<0.05),血清iPTH、ALP水平均低于术后3个月时(P<0.05)。术后6个月时皮肤瘙痒(4.84%)、睡眠障碍(3.23%)发生率及骨痛VAS评分[(1.96±0.91)分]均低于术前[80.65%、69.35%、(5.12±2.29)分](P<0.05)。随访至2020年4月,SHPT复发9例,出现持续性甲状旁腺功能低下5例。结论肾性SHPT患者行TPTX或TPTX+AT可有效缓解临床症状,降低血钙、血磷及血清iPTH、ALP水平,且围术期并发症、持续性甲状旁腺功能低下发生率及SHPT复发率低。

Objective To investigate the changes of serum calcium,serum phosphorus,serum intact parathyroid hormones(iPTH)and alkaline phosphatase(ALP)levels in patients with renal secondary hyperparathyroidism(SHPT)after total parathyroidectomy(TPTX)or total parathyroidectomy with autotransplantation(TPTX+AT),and to investigate the therapeutic effect and safety.Methods Sixty-two patients with renal SHPT underwent TPTX or TPTX+AT.The success rate of surgery and postoperative complications were recorded.The levels of serum calcium,serum phosphorus,serum iPTH and ALP were measured before operation and 1,3 and 6 months after operation.The visual analogue scale(VAS)score of bone pain,and incidences of pruritus and sleep disorders were compared before operation and 6 months after operation.The follow-up survey was done till April,2020,and the postoperative recurrence of SHPT and the incidence of postoperative persistent hypoparathyroidism were recorded.Results Of 62 patients,24 underwent TPTX and 38 underwent TPTX+AT,with the success rate of 100%.The grafts survival rate was 86.8%in patients undergoing TPTX+AT.There were no postoperative complications such as incision infection loss of laryngeal sensory nerves,aphonia or perioperative death.The levels of serum calcium,serum phosphorus,serum iPTH and ALP were lower 1 month after operation[(2.26±0.20)mmol/L,(1.09±0.29)mmol/L,73.74(64.50,86.26)ng/L,223.18(44.87,318.86)u/L],3 months after operation[(2.26±0.21)mmol/L,(1.28±0.25)mmol/L,72.37(64.13,84.40)ng/L,131.98(43.52,199.61)u/L]and 6 months after operation[(2.27±0.22)mmol/L,(1.33±0.24)mmol/L,71.11(60.06,83.04)ng/L,104.78(35.36,154.91)u/L]than those before operation[(2.66±0.15)mmol/L,(2.89±0.70)mmol/L,1277.32(1012.35,1423.85)ng/L,567.68(445.10,741.50)u/L](P<0.05).The level of serum phosphorus was lower 1month after operation than those 3and 6months after operation(P<0.05),and lower 3months after operation than that 6months after operation(P<0.05).The ALP level was lower3and 6months after operation than that 1 month after operation(P<0.05).The levels serum iPTH and ALP were lower 6months after operation than those 3 months after operation(P<0.05).The incidence of pruritus and sleep disorder as well as VAS score were lower 6months after operation(4.84%,3.23%,1.96±0.91)than those before operation(80.65%,69.35%,5.12±2.29)(P<0.05).Till April,2020,SHPT recurred in 9patients and persistent hypoparathyroidism occurred in 5.Conclusion TPTX or TPTX+AT can effectively relieve the clinical symptoms,reduce serum calcium,serum phosphorus,serum iPTH and ALP levels in patients with renal SHPT,and the incidence of perioperative complications and persistent hypoparathyroidism and SHPT recurrence rate are low.